Fraud, Waste, and Abuse
Medicare Fraud, Waste, and Abuse come from a series of laws enacted by The Social Security Act, The United States Criminal Code, The False Claims Act (FCA), The Anti-Kickback Statute (AKS), and The Physician Self-Referral Law (Stark Law). The laws protect all parties involved in Medicare and Medicaid. Penalties can include as much as $100,000 in fines, imprisonment, and extraction from all government health care programs.
Those who commit Medicare fraud probably think they’re helping themselves, but in the end they’re raising costs and creating a cycle of mistrust among carriers, agents, and beneficiaries.
[clickToTweet tweet=”The government loses millions each year due to health care fraud, causing prices to rise. ” quote=”The government loses millions each year due to health care fraud, causing prices to rise. “]
What Is Medicare Fraud?
Medicare fraud happens when a carrier, agent, or client adjusts data to fall in their financial favor. As an agent, it is important that you not only be careful with your own actions but also alert your clients of the penalties for any of the following:
- Knowingly making false claims or misrepresenting data
- Knowingly giving or receiving rewards for goods and services
- Promoting a specific health service
- Billing Medicare for appointments that never happened
- Billing Medicare for more services than what actually occurred
What Is Medicare Abuse?
Abuse surrounds unnecessary costs or fees, and it occurs often among the underinformed. Some examples are:
- Billing for unnecessary services
- Excessive purchases for supplies
- Misusing codes
What Are The Laws?
- False Claims Act (FCA) – Protects the government from being overcharged on goods or services. No proof of intent is required.
- Anti-Kickback Statute (AKS) – Cannot knowingly reward referrals for health care programs.
- Physician Self-Referral Law (Stark Law) – Doctors cannot make referrals to health care companies in which they have an interest.
- Criminal Health Care Fraud Statute – Cannot defraud; bill for unnecessary medical goods and services (like drugs that are not needed or wheelchairs for those who are not impaired).
To help fight Medicare fraud, waste, and abuse report any suspicious activity to 1-800-HHS-TIPS (1-800-447-8477). You can also describe the incident in up to ten pages and email it to HHSTips@oig.hhs.gov.
